Huge disadvantages for rural patients exposed

Jolyon Attwooll

23/06/2023 3:52:33 PM

New details in an already concerning picture have emerged in research carried out on behalf of the National Rural Health Alliance.

Royal FLying Doctor Service plane
Life expectancy in rural parts of the country is significantly less than in urban areas.

A new study weighing up healthcare investment across Australian regions has calculated that patients in rural areas face an average annual shortfall of almost $850 in health funding each year compared to their city counterparts.
The research by the Nous Group consultancy was commissioned by the National Rural Health Alliance (NRHA), which has 48 member organisations including the RACGP.
The study looked at expenditure across different areas, including figures from the MBS, PBS, and Royal Flying Doctor Service (RFDS). 
It also considered spending across different healthcare areas such general practice, dental care, allied health and other specialties, as well as tertiary care.
Details on the full-time equivalent (FTE) health practitioner workforce ranging from inner city areas (known as Modified Monash Model 1 or MMM 1) to the most inaccessible parts of the country (MMM 7) were also analysed.
The report, called ‘Evidence base for additional investment in rural health in Australia’, concluded there is an annual healthcare spending deficit of around $6.5 billion for the country’s more than seven million rural residents.
For NHRA chief executive Susi Tegen, the figure highlights the ‘alarming day-to-day realities for rural Australians unable to access equitable care’.
‘Over seven million people, who make up nearly a third of Australia’s population, experience a greater burden from illness and early death, in part due to inadequate funding for their healthcare,’ she said.
‘This is despite the significant contribution they make to Australia’s economy.’
While the issues facing rural healthcare have been well documented in recent years, RACGP Rural Chair Associate Professor Michael Clements says the report’s use of multiple data sources paints a more detailed picture of the challenges and inequities than usual.
‘The idea is that when we look at just Medicare data, or just prescription PBS data, or just hospital data, nobody’s giving the full picture proving that these rural and remote patients aren’t getting access to the same health dollars as everybody else,’ he told newsGP.
‘This is one of the more accurate depictions of the gradients in the health dollar.
‘It shows systems that are currently in place for funding don’t support rural and remote areas. They tend to centralise the health dollar, getting spent more on the city patient rather than remote and so we need to have novel funding solutions.’
Data included in the report shows the number of GP visits in very remote areas is half the rate in major cities (3.4 every year compared to 6.8 in 2020–21).
Age-standardised PBS expenditure per capita also drops from $515.60 in the city down to $304.51 in the most remote areas (MMM 6–7).
The report suggests that low GP access has a knock-on impact to allied health and medical sub-specialty services, as well as increasing hospital usage, which is notably higher – and more expensive – in more rural areas.  
‘The scarcity of healthcare professionals, including doctors, dentists, pharmacists, and allied health professionals, poses a significant challenge to rural areas in meeting their healthcare needs,’ the authors wrote.
As well as the gap in GP access, the research draws on data showing a huge difference in the number of non-GP medical specialists, going down from 189.3 FTE per 100,000 in cities to 11.4 in small rural towns and 24.1 in very remote areas.
‘Patients often prioritise health issues based on their level of urgency, which creates a significant volition gap to early presentation and preventive health access, especially when service access is difficult,’ the report states.
‘This means that patients may only seek care when their conditions become more severe, leading to poorer health outcomes.
‘If service access is difficult, patients are incentivised to prioritise care only when it is urgent, creating a volition gap to early presentation and preventive health access.’
A recent RFDS report highlighted the huge gaps in life expectancy of people in the most remote areas of the country, where in 2020 females died on average 19 years younger than their counterparts in major cities, with the figure standing at 13.9 years for males.
The researchers said perceptions of healthcare and ‘rural stoicism’ can act as barriers to seeking assistance, with decreasing health literacy in the more remote areas also having an impact. They were told there is a reliance on grants that are not far-reaching enough to support longer-term investment in sustainable services, and do not give enough certainty to retain clinicians.
In a press release about the research, the NHRA this week called for ‘a place-based multidisciplinary model of primary healthcare’ that would act in a similar way to Aboriginal Community Controlled Health Organisations (ACCHOs).
Associate Professor Clements believes the rationale is sound, but also comes with its challenges.
‘The concept of trying to package together resources from Federal, state, and perhaps even local regions to provide a health service is a good one,’ he said.
‘What they’re proposing is a very expensive model. You’re talking about a significant increase in money needing to be spent by the Federal and the State [Governments] to make it work.
‘Also, in and of itself, it’s not something that’s going to draw new staff in.
‘In general, we support the concept and I think it does have a role.
‘It does speak to the wider conversation about what we need to see in the remote communities. We need to see coordination, we need to see pooled funding, we need to see more money.’
Among other measures, the RACGP advocates more regional and rural placements to encourage medical students to work outside of metropolitan areas, as well as cutting red tape for international medical graduates.
The Federal Budget, which included a tripling of the bulk billing incentive from November this year, was welcomed by the RACGP Rural Chair, who called it ‘an excellent, rurally loaded Budget’.
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Dr Matthew Piche   25/06/2023 7:49:53 AM

There are two reasons not listed above that I would have thought would contribute to the large discrepancy in life expectancy:

Most patients who don't die prematurely in a rural locality probably end up closer to a city at a ripe old age, full of expensive life extending technologies such as pace makers and joint replacements.

The second explanation that seems to be missing in this article is that many remote patients are ATSI, and have much higher morbidity and earlier mortality.

I see people leave public hospital jobs is so called "burnout" that is not driven just by excessive work load, but by the pervasive feeling that you can't effect change. Trying to improve service delivery becomes a matter of negotiating with too many constraining factors - budgetary, interpersonal, and departmental. Doctors end up leaving to work as locums because they lose the motivation to keep fighting and decide that they want to be better taken care of. It is not usually a purely financial decision.

Dr Stewart James Jackson   25/06/2023 2:02:44 PM

The RACGP needs to get its registrars to rural areas which it isn’t doing. Rural practices already take medical students in large numbers. The RACGP needs to look at its own training program which is not fit for purpose in getting GP’s to where they are needed.